Are Asians Harder to Please? A Mixed-Methods Study of Racial/Ethnic Differences in Expectations and Evaluation of Health Care Experiences

Background: While Asians in the United States report poorer health care experiences than non-Hispanic whites, the underlying reasons for such difference remain unclear. We examined how expectations and norms surrounding evaluation among non-Hispanic whites, Chinese and South Asians, as applied to a standardized health care experience, explain the differences in reported health care experiences. Methods: A purposeful sample of 10 non-Hispanic whites, 11 Chinese and 12 South Asian patients were recruited from a large multispecialty ambulatory care practice in California. Participants first read a vignette describing an office visit and then were asked to evaluate the vignette using an experience of care (EOC) survey that consisted of 17 items selected from the CAHPS® Clinician and Group Survey (CG-CAHPS). After completing the EOC survey independently, participants took part in a cognitive interview to describe their interpretations of each EOC survey item, reasons for their rating choices and suggested improvements needed to meet their expectations. We conducted comparative analyses across racial/ethnic groups for 1) the proportion of “top-box” (the best) responses for each EOC survey item, 2) evaluation norms characterized by the “top-box” responses paired with corresponding narratives regarding “improvement needed,” and 3) narratives surrounding expectations, experiences and evaluation norms for each aspect of care on the EOC survey. Results: Non-Hispanic whites were more likely to give the “top-box” ratings and concordantly indicate “no improvement needed” compared to South Asians (P \u3c 0.05) and Chinese (P \u3c 0.05) patients. Regardless of the rating given, both Chinese and South Asians were more likely than non-Hispanic whites to avoid the “top box” and indicate “improvement needed” (P \u3c 0.05), echoed by their narratives reporting higher expectations regarding timeliness of visits, communicating with providers, and getting tests and referrals, which were often unmet. A common belief expressed by both Asian groups was that “top-box” ratings are reserved for situations that dramatically exceeded their expectations, which might in part explain their lower likelihood to give “top-box” ratings than non-Hispanic whites for the same situation. Conclusion: Higher expectations among South Asian and Chinese patients may in part explain their poorer reported experiences. Further, the same care experience tends to be rated as poorer by Asians than non-Hispanic whites, which may also contribute to the lower ratings of health care experiences among Asian patients